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 Medical
Homes in Massachusetts
This page is designed to keep you informed about events
and activities happening in Massachusetts that will help improve
access to medical homes for children with special health care
needs (CSHCN).
Click on a topic below to learn more about what's
going on in Massachusetts
For individuals that attended the Medical Home Training
Program at Boston Shriners Burns Hospital, we hope that
you will use the information here to help put into practice
what you learned, as well as encourage you to participate
in other activities around the state.
Medical Home Initiatives
This section provides information on
state medical home initiatives/programs. States that are
a part of the mentorship
network will have a "Promise to the State"
which outlines how they will achieve ensuring that all children
have a medical home by 2010. This is based on the Healthy
People 2010 goals which is a 10 year action plan to
achieve and
measure
success for all CSHCN.
Massachusetts Medical Home Contact:
Name: Connie Carroll, Director of Care Coordination and Medical Home Initiatives
Contact: Email:
connie.carroll@state.ma.us
State Team
Roster
The
Commonwealth of Massachusetts
has
been awarded an MCHB State Implementation Grant for Integrated
Community Systems of Services for CSHCN
- Abstract
Contact Person: Nicole Roos, MBA. nicole.roos@state.ma.us
Goals and Objectives:
Goal 1: Build system capacity for family-professional
partnerships statewide
Goal 2: Enhance medical provider capacity
for providing medical homes for CYSHCN
Goal 3: Assure children receive early and
continuous screening and referral to appropriate services
Goal 4: Build system capacity for ensuring
YSHCN receive services necessary to make successful transitions
to adult life
Goal 5: Strengthen collaboration of youth,
families, providers, and state agencies in enhancing systems
of care for CYSHCN
Goals 6: Enhance advocacy skills of youth
and families
Massachusetts Statewide Medical Home Implementation
Plan -
Promise to the State 
The MA Medical Home Initiatives Steering Committee (comprised
of families, MCAAP, Consortium for CSHCN, Title V/DPH, AAP
CATCH, and the MA Chapter of Family Physicians) have written
a plan outlining specific goals for the state to achieve
a system of care in which all CSHCN have access to a medical
home by 2010.
MCHB Medical Home Grant "The Massachusetts
Medical Home Project": Abstract"
A medical home development project funded by the MCHB which
partners care coordinators from the Dept of Public Health
with primary care pediatricians in the community.
Healthy Tomorrows Partnership for Children Grant
2002-2007
The Worcester Medical Home Initiative
Purpose: The goal of the project is to improve
health outcomes by creating medical homes for children
with special health care needs attending the 2 pediatric
and 1 family practice office sites. We will use evaluation
tools to measure the organization and delivery of primary
care services in supporting chronic condition management,
care coordination, community outreach, data management,
and quality improvement. Simultaneously, families will
participate in an evaluation to measure emotional, physical,
social, health, and developmental progress as well as
consumer satisfaction. For more information
on this project click
here.
Advocating Success For Kids (ASK)
Children's Hospital, Boston, MA
Children's academic success during preschool and primary
grades may be compromised by developmental concerns caused
or exacerbated by psychosocial stressors such as substandard
housing, complex family situations, substance use, and
domestic violence. In partnership with the Boston Public
Schools and 6 community-based urban primary care sites,
the Advocating Success for Kids (ASK) program will provide
diagnostic consultations and follow-up visits for children
presenting with behavioral, developmental, or learning
difficulties that impair their ability to learn effectively
in their classrooms. A multidisciplinary ASK team, consisting
of a psychologist, educator, developmental pediatrician,
and case manager, will meet with families at their community
health center and provide case coordination-linking families
with indicated educational, medical, and psychosocial
support services.
Goals of the ASK program are to work with families, primary
care providers, and the local school system to: improve
school readiness and performance of children ages 3 to
9 years; and improve the emotional well-being of children
served through the ASK program.
For more information on the Healthy Tomorrows Grant Program
click
here. For
more information on any of these HTPCP projects, please
e-mail your name, address, telephone, and fax numbers
with your specific request to healthyt@aap.org..
Medical Home Materials
- Medical Home Brochure for Families:
Brochure
A NEW WAY…A BETTER WAY. THE MEDICAL HOME PARTNERSHIP:
Building a Home Base for Your Child with Special Health
Care Needs
- Medical Home Brochure for Providers: Brochure
SMALL STEPS…BIG DIFFERENCES. THE MEDICAL HOME PARTNERSHIP:
Practical Tips for Physicians Caring for Children with
Special Health Care Needs
- Care Coordination Program for CSHCN: A
Resource for Parents and Providers
Brochure
- Programa de Coordinación de servicios
para niños con necidades especiales médicas:
Un recurso para padres y proveedores
Brochure
Related Grant Initiatives
This section provides information on
current state grants that are working on medical home initiatives.
This includes the grant abstract as well as key contacts
for the grant.
Healthy Tomorrows Partnership for Children Grants
Family Advocates of Central Massachusetts
Providing a Medical Home for children of low-income
families includes the capacity to address the legal issues
that affect the health of children and families. Family
Advocates of Central Massachusetts will incorporate attorneys
from LACCM as full members of the multidisciplinary teams
caring for children from low-income families in four practices
located in Worcester, Webster, Milford and Fitchburg Massachusetts.
The attorneys will work closely with health care providers
to develop a system of care that integrates legal advice
and representation as an additional tool to address the
social issues within families that adversely affect the
health of children. The attorneys will develop screening
protocols and staff trainings that fit within the organizational
culture of the four medical practices. Each year, they will
provide counsel and advice to more than 100 low-income families
with children, and will provide full representation to more
than 30 low-income families with children, at the four practice
sites in Central Massachusetts.
Projects Goals & Objectives: The goals
of this project are: 1) To improve housing stability, 2)
To improve financial security, 3) To improve dignity and
safety, and 4) To improve access to health care.
For more information on the Healthy Tomorrows Grant Program
click
here. For
more information on any of these HTPCP projects, please
e-mail your name, address, telephone, and fax numbers with
your specific request to healthyt@aap.org.
Genetics Grant: Abstract
Project period: 3 years from 6/1/2001 to
5/31/2004
The goals of the project are to: 1) Assure
access to care coordination and timely referral to services
for CSHCN (particularly children identified through newborn
hearing screening, newborn metabolic screening, and FIRSTLink
electronic screening of birth certificates to identify newborns
at risk) and through genetics diagnostic centers; 2) Establish
an integrated child health data system across Department
of Public Health (DPH) programs with links to the medical
homes of CSHCN and with personal access for families served
by participant programs; and 3) Increase community and program
staff genetics knowledge and capacity, as outlined in the
state Genetics Strategic Plan.
Hemophilia Grant: Abstract
Project Period: 1 Year From: 6/01/01 to
5/31/02
The goal of the region I core hemophilia program is to provide
culturally sensitive, family centered, comprehensive care
services to individuals with hemophilia and other coagulopathies.
Partners in the State
This section provides information on who in the state
(individuals and agencies) are working together to create
medical homes for children.
American Academy of Pediatrics (AAP) Chapter:www.mcaap.org/
American Academy of Family Physicians (AAFP) Chapter:
www.massafp.org/
Title V CSHCN Program - "The Division for
Special Health Needs" www.mass.gov/dph/fch/dshn.htm
Title V Block Grant to States
Title V of the Social Security Act is one of the largest
Federal block grant programs. It leads the nation in ensuring
the health of all mothers, infants, children, adolescents,
and children with special health care needs (CSHCN). Title
V is administered by the Maternal and Child Health Bureau
(MCHB) as part of the Health Resources and Services Administration,
U.S. Department of Health and Human Services.
Title V and Children with Special Health Care
Needs
MCHB Objective: Support development and
implementation of comprehensive, culturally competent,
coordinated systems of care for the estimated 18 million
U.S. children who have or are at risk for chronic physical,
developmental, behavioral or emotional conditions and
who also require health and related services of a type
or amount beyond that required by children generally.
Early Hearing Detection & Intervention (EHDI) Contact(s):
State EHDI programs promote universal newborn hearing screening,
develop effective tracking and follow-up as a part of the
public health system, promote appropriate and timely diagnosis
of the hearing loss, prompt enrollment in appropriate Early
Intervention, link newborns to a medical
home and strive to eliminate geographic and financial barriers
to service access.
Name: Janet M. Farrell
Contact: Phone: 617-624-5957 | Fax: 617-624-5990
E-mail: janet.farrell@state.ma.us
Early Intervention/Part C Coordinator:
The Program for Infants and Toddlers with Disabilities (Part
C of IDEA) is a federal grant program that assists states
in operating a comprehensive statewide program of early
intervention services for infants and toddlers with disabilities,
ages birth through age 2 years, and their families.
Name: Ron Benham, Part C Coordinator
and Director of EI
Contact: Phone: (617) 624-5962 | Fax:
(617) 624-5990 | AltPhone1: (617) 624-5070
Email:
ron.benham@state.ma.us
Website: www.mass.gov/dph/fch/ei.htm
Section 619/ Preschool Grants Program of the Individuals
with Disabilities Education Act (IDEA). This program
provides free appropriate public education (FAPE) for children,
ages 3 through 5 years, with disabilities:
Name: Russell Hoyt, 619 Coordinator
Contact: (781) 338-6360 (Hoyt) | Fax:
(781) 338-3370 | Email: rhoyt@doe.mass.edu
Name: Elisabeth Schaefer, Administrator
Contact: Phone: (781) 338-6357 (Schaefer)
| Fax: (781) 338-3380
Email: eschaefer@doe.mass.edu
Website: www.doe.mass.edu/els/
State Interagency Coordinating Council (ICC) Chairs:
The ICC advises appropriate agencies on the unmet needs
in early childhood special education and early intervention
programs for children with disabilities, assists in the
development and implementation of policies that constitute
a statewide system, and assists all appropriate agencies
in achieving full participation, coordination, and cooperation
for implementation of statewide system.
Name: Barbara Prindle Eaton, ICC Chair
Contact: Phone: (508) 775-6240 | Fax:
(508) 790-4774 | Email: bpeaton@cccdp.org
Resources/Documents
Practicing
Comprehensive Care: A Physician's Operations Manual for
Implementing a Medical Home for CSHCN - created by the
Pediatric Alliance for Coordinated Care, the manual offers
practical advice and suggestions to support the day-to-day
operations of pediatric offices to more efficiently and
effectively serve children with special health care needs.
Transition
Planning for Adolescents with Special Health Care Needs
and Disabilities: A Guide for Health Care Providers (2000)
- The guide gives information, resources and strategies
needed by providers to support adolescents and their families
to meet the challenges of transition.
Transition
Planning for Adolescents with Special Health Care Needs
and Disabilities: Information for Families and Teens (2000)
- This booklet has been developed for families to help you
prepare with your teen for his/her adulthood.
Partnerships
For Quality - Click here for transcripts and
resources from this conference held by MA Family Voices
that brought together families and health professionals
to discuss how to improve care for CSHCN.
State Waiver Information: www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/08_WavMap.asp
Waivers are the result of a process that allows state Medicaid
agencies to apply for and receive permission from HCFA to
provide services not otherwise covered by Medicaid and/or
to do so in ways not described by the Social Security Act.
Most Medicaid managed care programs require Waivers. The
Waivers, which can differ greatly, are known by their numbers
(1115, 1119), or as home-and community-based, or as Katie
Beckett Waivers.
Educational Initiatives
This section provides information
on training initiatives on the medical home. Some states
will discuss their outreach projects in relation to physicians,
families, and the community.
The Medical Home Network Project: www.neserve.org/neserve/wwd_med_hm.html
This educational program of New England SERVE brings together
primary care providers, parents and community partners to
demystify the theory and practice of the Medical Home. Its
case-based curriculum offers knowledge, awareness, and strategies
for implementing small practice improvements. Sessions include:
- Introduction to Medical Home, CSHCN, Family Centered
Care
- Community Resources and Care Coordination
- Medical Home Index and Practice Change
These two-hour sessions carry continuing medical education
(CME) approval.This project is ongoing.
Screening
Initiatives
This section provides information on surveillance
and screening initiatives in the state.
State Newborn Screening & Genetics Programs:
genes-r-us.uthscsa.edu/resources.htm
- State Newborn Screening
Program Links
- State Genetics Program
Links
- Regional Genetics and
Newborn Screening
Collaborative Links
- Newborn Screening
State Contact Fact
Sheet
State Resources on the Internet
Note: The information provided on the state pages was submitted
by the state medical home teams.As this is not an exhaustive
list, please let us know if you have additions for your
state resource page. You can contact us at: medical
home@aap.org.
Last Updated
August 15, 2006
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